Clinical practice guidelines for the perioperative nutritional,metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: Cosponsored by american association of clinical endocrinologists,The obesity society,and american society for metabolic & bariatric surgery*

Abstract:

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re‐evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type‐2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE‐TOS‐ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.     

American Association Of Clinical Endocrinologists And American College Of Endocrinology Guidelines For Management Of Dyslipidemia And Prevention Of Cardiovascular Disease - Executive Summary

Objective: The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).Methods: Each Recommendation is based on a diligent review of the clinical evidence with transparent incorporation of subjective factors.Results: The Executive Summary of this document contains 87 Recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 202 (29.1 %) are evidence level (EL) 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 237 (34.1%) are EL 4 (no clinical evidence).Conclusion: This CPG is a practical tool that endocrinologists, other healthcare professionals, regulatory bodies and health-related organizations can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of patients with various lipid disorders. These recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously recommended and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to patients with diabetes, familial hypercholesterolemia, women, and pediatric patients with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions.AbbreviationsA1C = hemoglobin A1CACE = American College of EndocrinologyACS = acute coronary syndromeAHA = American Heart AssociationASCVD = atherosclerotic cardiovascular diseaseATP = Adult Treatment Panelapo = apolipoproteinBEL = best evidence levelCKD = chronic kidney diseaseCPG = clinical practice guidelinesCVA = cerebrovascular accidentEL = evidence levelFH = familial hypercholesterolemiaHDL-C = high-density lipoprotein cholesterolHeFH = heterozygous familial hypercholesterolemiaHIV = human immunodeficiency virusHoFH = homozygous familial hypercholesterolemiahsCRP = high-sensitivity C-reactive proteinLDL-C = low-density lipoprotein cholesterolLp-PLA₂ = lipoprotein-associated phospholipase A₂MESA = Multi-Ethnic Study of AtherosclerosisMetS = metabolic syndromeMI = myocardial infarctionNCEP = National Cholesterol Education ProgramPCOS = polycystic ovary syndromePCSK9 = proprotein convertase subtilisin/kexin type 9T1DM = type 1 diabetes mellitusT2DM = type 2 diabetes mellitusTG = triglyceridesVLDL-C = very low-density lipoprotein cholesterol     

American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis— 2020 Update Executive Summary

Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options.Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis.     

American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity

Objective: Development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and the American College of Endocrinology (ACE) Board of Trustees and adheres to published AACE protocols for the standardized production of clinical practice guidelines (CPGs).Methods: Recommendations are based on diligent review of clinical evidence with transparent incorporation of subjective factors.Results: There are 9 broad clinical questions with 123 recommendation numbers that include 160 specific statements (85 [53.1%] strong [Grade A], 48 [30.0%] intermediate [Grade B], and 11 [6.9%] weak [Grade C], with 16 [10.0%] based on expert opinion [Grade D]) that build a comprehensive medical care plan for obesity. There were 133 (83.1%) statements based on strong (best evidence level [BEL] 1 = 79 [49.4%]) or intermediate (BEL 2 = 54 [33.7%]) levels of scientific substantiation. There were 34 (23.6%) evidence-based recommendation grades (Grades A-C = 144) that were adjusted based on subjective factors. Among the 1,788 reference citations used in this CPG, 524 (29.3%) were based on strong (evidence level [EL] 1), 605 (33.8%) were based on intermediate (EL 2), and 308 (17.2%) were based on weak (EL 3) scientific studies, with 351 (19.6%) based on reviews and opinions (EL 4).Conclusion: The final recommendations recognize that obesity is a complex, adiposity-based chronic disease, where management targets both weight-related complications and adiposity to improve overall health and quality of life. The detailed evidence-based recommendations allow for nuanced clinical decision-making that addresses real-world medical care of patients with obesity, including screening, diagnosis, evaluation, selection of therapy, treatment goals, and individualization of care. The goal is to facilitate high-quality care of patients with obesity and provide a rational, scientific approach to management that optimizes health outcomes and safety.Abbreviations:A1C = hemoglobin A1cAACE = American Association of Clinical EndocrinologistsACE = American College of EndocrinologyAMA = American Medical AssociationBEL = best evidence levelBMI = body mass indexCCO = Consensus Conference on ObesityCPG = clinical practice guidelineCSS = cross-sectional studyCVD = cardiovascular diseaseEL = evidence levelFDA = Food and Drug AdministrationGERD = gastroesophageal reflux diseaseHDL-c = high-density lipoprotein cholesterolIFG = impaired fasting glucoseIGT = impaired glucose toleranceLDL-c = low-density lipoprotein cholesterolMNRCT = meta-analysis of non-randomized prospective or case-controlled trialsNE = no evidencePCOS = polycystic ovary syndromeRCT = randomized controlled trialSS = surveillance studyU.S = United States     

American Association of Clinical Endocrinologists and American College of Endocrinology Protocol for Standardized Production of Clinical Practice Guidelines,Algorithms, and Checklists - 2014 Update and the AACE G4G Program

In 2010, the American Association of Clinical Endocrinologists (AACE) published an update to the original 2004 guidelines. This update hybridized strict evidence-based medicine methods with subjective factors and improved the efficiency of clinical practice guidelines (CPG) production, clinical applicability, and usefulness. Current and persistent shortcomings involving suboptimal implementation and protracted development timelines are addressed in the current 2014 update. The major advances include 1) formulation of an organizational educational strategy, represented by the AACE Council on Education, to address relevant teaching and decision-making tools for clinical endocrinologists, and to generate specific clinical questions to drive CPG, clinical algorithm (CA), and clinical checklist (CC) development; 2) creation and prioritization of printed and online CAs and CCs with a supporting evidence base; 3) focus on clinically relevant and question-oriented topics; 4) utilization of "cascades," where there can be more than 1 recommendation for 1 clinical question; and 5) incorporation of performance metrics to validate, optimize, and effectively update CPG, CAs, and CCs. Efforts continue to translate these clinical tools to electronic formats that can be integrated into a paperless healthcare delivery system, as well as applying them to diverse clinical settings by incorporating transcultural factors. (Endocr Pract. 2014;20:000-000)     

“Metabolic” Surgery For Treatment Of Type 2 Diabetes Mellitus

ObjectiveTo discuss the potential contribution of “metabolic” surgery in providing optimal management of patients with type 2 diabetes mellitus (T2DM).MethodsA literature search was performed with use of PubMed, and the clinical experience of the authors was also considered.ResultsBariatric—or, more appropriately, metabolic—surgical procedures have been shown to provide dramatic improvement in blood glucose levels, blood pressure, and lipid control in obese patients with T2DM. In these patients, metabolic surgery involves a low risk of short-term mortality and a significant long-term survival advantage, whereas the diagnosis of diabetes is associated with significant long-term mortality. Experimental studies in animals and clinical trials suggest that gastrointestinal bypass procedures can control diabetes and associated metabolic alterations by mechanisms independent of weight loss. As a result, the use of bariatric surgery and experimental gastrointestinal manipulations to treat T2DM is increasing, even among less obese patients. Although body mass index (BMI) currently is the most important factor for identifying candidates for bariatric surgery, evidence shows that a specific cutoff BMI value cannot accurately predict successful surgical outcomes. Furthermore, BMI appears limited in defining the risk profile for patients with T2DM.ConclusionCurrent BMI-based criteria for performance of bariatric surgery are not adequate for determining eligibility for operative treatment in patients with diabetes. Large clinical trials, comparing bariatric surgery versus optimal medical care of patients with T2DM, should be given priority in order to define the role of surgery in the management of diabetes. Recognizing the need to work as a multidisciplinary team that includes endocrinologists and surgeons is an initial step in addressing the issues and opportunities that surgery offers to diabetes care and research. (Endocr Pract. 2009;15:624-631)     

Transculturalization Recommendations For Developing Latin American Clinical Practice Algorithms In Endocrinology Proceedings Of The 2015 Pan-American Workshop By The American Association Of Clinical Endocrinologists And American College Of Endocrinology

The American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) convened their first Workshop for recommendations to optimize Clinical Practice Algorithm (CPA) development for Latin America (LA) in diabetes (focusing on glycemic control), obesity (focusing on weight loss), thyroid (focusing on thyroid nodule diagnostics), and bone (focusing on postmenopausal osteoporosis) on February 28, 2015, in San Jose, Costa Rica. A standardized methodology is presented incorporating various transculturalization factors: resource availability (including imaging equipment and approved pharmaceuticals), health care professional and patient preferences, lifestyle variables, socio-economic parameters, web-based global accessibility, electronic implementation, and need for validation protocols. A standardized CPA template with node-specific recommendations to assist the local transculturalization process is provided. Participants unanimously agreed on the following five overarching principles for LA: (1) there is only one level of optimal endocrine care, (2) hemoglobin A1C should be utilized at every level of diabetes care, (3) nutrition education and increased pharmaceutical options are necessary to optimize the obesity care model, (4) quality neck ultrasound must be part of an optimal thyroid nodule care model, and (5) more scientific evidence is needed on osteoporosis prevalence and cost to justify intervention by governmental health care authorities. This 2015 AACE/ACE Workshop marks the beginning of a structured activity that assists local experts in creating culturally sensitive, evidence-based, and easy-to-implement tools for optimizing endocrine care on a global scale.Abbreviations:A1C = glycated hemoglobinAACE = American Association of Clinical EndocrinologistsACE = American College of EndocrinologyBG = blood glucoseBMI = body mass indexCPA = Clinical Practice AlgorithmCPG = Clinical Practice GuidelineCVD = cardiovascular diseaseDXA = dual-energy X-ray absorptiometryEDC = endocrine-disrupting compoundFBG = fasting blood glucoseFNA = fine-needle aspirationHCP = health care professionalLA = Latin AmericaPAACE = Pan-American AACESU = sulfonylureaT2D = type 2 diabetestDNA = transcultural Diabetes Nutrition AlgorithmTSH = thyroid-stimulating hormoneWC = waist circumferenceWHO = World Health Organization     

Bariatric Surgery and the Role of the Clinical Endocrinologist: 2011 Update

ObjectiveTo discuss the emerging roles of bariatric surgery and clinical endocrinology within the context of obesity and diabetes mellitus comprehensive care plans and cost-effective strategies.MethodsRelevant literature is reviewed and clinical cases are presented.ResultsThe global obesity epidemic poses many challenges to clinical endocrinologists and has fomented a coordinated effort among specialists to revolutionize management paradigms. Technologic innovation drives the need for accelerated learning and research efforts in bariatric surgery. The national shortage of physicians with expertise in nutritional medicine compounds the management problems for this expanding patient population. Certain issues merit continued attention and research, such as gastric banding for mild obesity, surgery for treatment of diabetes, sleeve gastrectomy, and nutritional and metabolic consequences.ConclusionClinical endocrinologists should have a central role in the perioperative decision-making for patients undergoing bariatric surgery. (Endocr Pract. 2011;17:788-797)     

The Controversy Over Pediatric Bariatric Surgery

Despite the reported limited success of conventional treatments and growing evidence of the effectiveness of adult bariatric surgery, weight loss operations for (morbidly) obese children and adolescents are still considered to be controversial by health care professionals and lay people alike. This paper describes an explorative, qualitative study involving obesity specialists, morbidly obese adolescents, and parents and identifies attitudes and normative beliefs regarding pediatric bariatric surgery. Views on the etiology of obesity—whether it should be considered primarily a medical condition or more a psychosocial problem—seem to affect the specialists’ normative opinions concerning the acceptability of bariatric procedures as a treatment option, the parents’ feelings regarding both being able to influence their child’s health and their child being able to control their own condition, and the adolescents’ sense of competence and motivation for treatment. Moreover, parents and adolescents who saw obesity as something that they could influence themselves were more in favor of non-surgical treatment and vice versa. Conflicting attitudes and normative views—e.g., with regard to concepts of disease, personal influence on health, motivation, and the possibility of a careful informed consent procedure—play an important role in the acceptability of bariatric surgery for childhood obesity.     

American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Growth Hormone Deficiency in Adults and Patients Transitioning from Pediatric to Adult Care

Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPG).Methods: Recommendations are based on diligent reviews of clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.Results: The Executive Summary of this 2019 updated guideline contains 58 numbered recommendations: 12 are Grade A (21%), 19 are Grade B (33%), 21 are Grade C (36%), and 6 are Grade D (10%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 357 citations of which 51 (14%) are evidence level (EL) 1 (strong), 168 (47%) are EL 2 (intermediate), 61 (17%) are EL 3 (weak), and 77 (22%) are EL 4 (no clinical evidence).Conclusion: This CPG is a practical tool that practicing endocrinologists and regulatory bodies can refer to regarding the identification, diagnosis, and treatment of adults and patients transitioning from pediatric to adult-care services with growth hormone deficiency (GHD). It provides guidelines on assessment, screening, diagnostic testing, and treatment recommendations for a range of individuals with various causes of adult GHD. The recommendations emphasize the importance of considering testing patients with a reasonable level of clinical suspicion of GHD using appropriate growth hormone (GH) cut-points for various GH–stimulation tests to accurately diagnose adult GHD, and to exercise caution interpreting serum GH and insulin-like growth factor-1 (IGF-1) levels, as various GH and IGF-1 assays are used to support treatment decisions. The intention to treat often requires sound clinical judgment and careful assessment of the benefits and risks specific to each individual patient. Unapproved uses of GH, long-term safety, and the current status of long-acting GH preparations are also discussed in this document.LAY ABSTRACTThis updated guideline provides evidence-based recommendations regarding the identification, screening, assessment, diagnosis, and treatment for a range of individuals with various causes of adult growth-hormone deficiency (GHD) and patients with childhood-onset GHD transitioning to adult care. The update summarizes the most current knowledge about the accuracy of available GH–stimulation tests, safety of recombinant human GH (rhGH) replacement, unapproved uses of rhGH related to sports and aging, and new developments such as long-acting GH preparations that use a variety of technologies to prolong GH action. Recommendations offer a framework for physicians to manage patients with GHD effectively during transition to adult care and adulthood. Establishing a correct diagnosis is essential before consideration of replacement therapy with rhGH. Since the diagnosis of GHD in adults can be challenging, GH–stimulation tests are recommended based on individual patient circumstances and use of appropriate GH cut-points. Available GH–stimulation tests are discussed regarding variability, accuracy, reproducibility, safety, and contraindications, among other factors. The regimen for starting and maintaining rhGH treatment now uses individualized dose adjustments, which has improved effectiveness and reduced reported side effects, dependent on age, gender, body mass index, and various other individual characteristics. With careful dosing of rhGH replacement, many features of adult GHD are reversible and side effects of therapy can be minimized. Scientific studies have consistently shown rhGH therapy to be beneficial for adults with GHD, including improvements in body composition and quality of life, and have demonstrated the safety of short- and long-term rhGH replacement.Abbreviations: AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AHSG = alpha-2-HS-glycoprotein; AO-GHD = adult-onset growth hormone deficiency; ARG = arginine; BEL = best evidence level; BMD = bone mineral density; BMI = body mass index; CI = confidence interval; CO-GHD = childhood-onset growth hormone deficiency; CPG = clinical practice guideline; CRP = C-reactive protein; DM = diabetes mellitus; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = Food and Drug Administration; FD-GST = fixed-dose glucagon stimulation test; GeNeSIS = Genetics and Neuroendocrinology of Short Stature International Study; GH = growth hormone; GHD = growth hormone deficiency; GHRH = growth hormone–releasing hormone; GST = glucagon stimulation test; HDL = high-density lipoprotein; HypoCCS = Hypopituitary Control and Complications Study; IGF-1 = insulin-like growth factor-1; IGFBP = insulin-like growth factor–binding protein; IGHD = isolated growth hormone deficiency; ITT = insulin tolerance test; KIMS = Kabi International Metabolic Surveillance; LAGH = long-acting growth hormone; LDL = low-density lipoprotein; LIF = leukemia inhibitory factor; MPHD = multiple pituitary hormone deficiencies; MRI = magnetic resonance imaging; P-III-NP = procollagen type-III amino-terminal pro-peptide; PHD = pituitary hormone deficiencies; QoL = quality of life; rhGH = recombinant human growth hormone; ROC = receiver operating characteristic; RR = relative risk; SAH = subarachnoid hemorrhage; SDS = standard deviation score; SIR = standardized incidence ratio; SN = secondary neoplasms; T3 = triiodothyronine; TBI = traumatic brain injury; VDBP = vitamin D-binding protein; WADA = World Anti-Doping Agency; WB-GST = weight-based glucagon stimulation test     

Mental Health in Bariatric Surgery: Selection,Access, and Outcomes

Severe obesity has many psychiatric consequences that can be influenced by bariatric surgery. The goal of this article is to review these challenges, including the mental health status of patients with severe obesity, the evaluation of surgical candidates, and the early and late effects of the operations, and to offer some recommendations to manage these challenges. The failure of the insurance‐mandated preoperative psychosocial evaluation is also discussed.     

Appropriateness Criteria for Bariatric Surgery: Beyond the NIH Guidelines

Careful selection of bariatric patients is critical for successful outcomes. In 1991, the NIH first established patient selection guidelines; however, some surgeons operate on individuals outside of these criteria, i.e., extreme age groups. We developed appropriateness criteria for the spectrum of patient characteristics including age, BMI, and severity of eight obesity‐related comorbidities. Candidate criteria were developed using combinations of patient characteristics including BMI: ≥40 kg/m², 35–39, 32–34, 30–31, <30; age: 12–18, 19–55, 56–64, 65+ years old; and comorbidities: prediabetes, diabetes, hypertension, dyslipidemia, sleep apnea, venous stasis disease, chronic joint pain, and gastroesophageal reflux (plus severity level). Criteria were formally validated on their appropriateness of whether the benefits of surgery clearly outweighed the risks, by an expert panel using the RAND/UCLA modified Delphi method. Nearly all comorbidity severity criteria for patients with BMI ≥40 kg/m² or BMI = 35–39 kg/m² in intermediate age groups were found to be appropriate for surgery. In contrast, patients in the extreme age categories were considered appropriate surgical candidates under fewer conditions, primarily the more severe comorbidities, such as diabetes and hypertension. For patients with a BMI of 32–34, only the most severe category of diabetes (Hgb A1c >9, on maximal medical therapy), is an appropriate criterion for those aged 19–64, whereas many mild to moderate severity comorbidity categories are “inappropriate.” There is overwhelming agreement among the panelists that the current evidence does not support performing bariatric surgery in lower BMI individuals (BMI <32). This is the first development of appropriateness criteria for bariatric surgery that includes severity categories of comorbidities. Only for the most severe degrees of comorbidities were adolescent and elderly patients deemed appropriate for surgery. Patient selection for bariatric procedures should include consideration of both patient age and comorbidity severity.     

Psychosocial and Behavioral Aspects of Bariatric Surgery

Bariatric surgery has become an increasingly popular treatment option for individuals with extreme obesity (defined as a BMI ≥ 40 kg/m²) or those with less severe obesity accompanied by significant comorbidities. Sustained postoperative weight loss and improvements in obesity‐related health problems make bariatric surgery the most effective treatment for this population. Nevertheless, most experts agree that psychosocial and behavioral factors contribute to successful postoperative outcomes. This paper reviews the literature on the preoperative psychosocial status, eating behaviors, and quality of life of patients who seek bariatric surgery. In addition, the paper examines studies that investigated changes in these factors postoperatively. The review concludes with an agenda for future research in this area.     

Application Of The Aace/Ace Advanced Framework For The Diagnosis Of Obesity And Cardiometabolic Disease Staging In A General Population From 3 Regions Of Venezuela: The Vemsols Study Results

Objective: To determine the prevalence of obesity according to the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) framework based on a complications-centric model with further application of the Cardiometabolic Disease Staging (CMDS) system in a Venezuelan population.Methods: A total of 1,320 adults were randomly selected from 3 regions. The AACE/ACE framework definitions were as follows: overweight, body mass index (BMI) 25 to 29.9 kg/m² and no obesity-related complications (ORC); obesity stage 0, BMI ≥30 and no ORC; stage 1, BMI ≥25 and 1 or more mild-to-moderate ORC; and stage 2, BMI ≥25 and 1 or more severe ORC. CMDS definitions were as follows: stage 0, no metabolic syndrome (MS) components; stage 1, 1 to 2 MS components without impaired fasting glucose (IFG); stage 2, IFG or ≥3 MS components but without IFG; stage 3, IFG and MS; and stage 4, type 2 diabetes (T2D) or cardiovascular disease.Results: The mean age was 44.8 ± 0.4 years, and 68.5% were female. The prevalence of obesity according to the AACE/ACE framework was 63.1%: overweight 3.0% (95% confidence interval &lsqb;CI]: 2.1–3.9); obesity stage 0: 0.1% (0.07–0.27); obesity stage 1: 26.6% (24.2–29.0); and obesity stage 2: 36.4% (33.8–39.0). Most subjects with a BMI <25 were CMDS 0 or 1. In those with BMI ≥ 25, only 4.6% were CMDS 0. The prevalence of obesity according to the World Health Organization (WHO, BMI ≥30) was 29.3% (24.7–33.7).Conclusion: In a general population study, applying the AACE/ACE framework for obesity and CMDS increased the detection of ORC and therefore higher risk subjects compared to classic anthropometric measurements.Abbreviations: AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; BMI = body mass index; CMDS = Cardiometabolic Disease Staging; DALY = disability-adjusted life years; LA = Latin America; MS = metabolic syndrome; ORC = obesity-related complications; WC = waist circumference; WHO = World Health Organization     

Bariatric Surgery in the United Kingdom: A Cohort Study of Weight Loss and Clinical Outcomes in Routine Clinical Care

Background

Bariatric surgery is becoming a more widespread treatment for obesity. Comprehensive evidence of the long-term effects of contemporary surgery on a broad range of clinical outcomes in large populations treated in routine clinical practice is lacking. The objective of this study was to measure the association between bariatric surgery, weight, body mass index, and obesity-related co-morbidities.

Methods and Findings

This was an observational retrospective cohort study using data from the United Kingdom Clinical Practice Research Datalink. All 3,882 patients registered in the database and with bariatric surgery on or before 31 December 2014 were included and matched by propensity score to 3,882 obese patients without surgery. The main outcome measures were change in weight and body mass index over 4 y; incident diagnoses of type 2 diabetes mellitus (T2DM), hypertension, angina, myocardial infarction (MI), stroke, fractures, obstructive sleep apnoea, and cancer; mortality; and resolution of hypertension and T2DM. Weight measures were available for 3,847 patients between 1 and 4 mo, 2,884 patients between 5 and 12 mo, and 2,258 patients between 13 and 48 mo post-procedure. Bariatric surgery patients exhibited rapid weight loss for the first four postoperative months, at a rate of 4.98 kg/mo (95% CI 4.88–5.08). Slower weight loss was sustained to the end of 4 y. Gastric bypass (6.56 kg/mo) and sleeve gastrectomy (6.29 kg/mo) were associated with greater initial weight reduction than gastric banding (2.77 kg/mo). Protective hazard ratios (HRs) were detected for bariatric surgery for incident T2DM, 0.68 (95% CI 0.55–0.83); hypertension, 0.35 (95% CI 0.27–0.45); angina, 0.59 (95% CI 0.40–0.87);MI, 0.28 (95% CI 0.10–0.74); and obstructive sleep apnoea, 0.55 (95% CI 0.40–0.87). Strong associations were found between bariatric surgery and the resolution of T2DM, with a HR of 9.29 (95% CI 6.84–12.62), and between bariatric surgery and the resolution of hypertension, with a HR of 5.64 (95% CI 2.65–11.99). No association was detected between bariatric surgery and fractures, cancer, or stroke. Effect estimates for mortality found no protective association with bariatric surgery overall, with a HR of 0.97 (95% CI 0.66–1.43). The data used were recorded for the management of patients in primary care and may be subject to inaccuracy, which would tend to lead to underestimates of true relative effect sizes.

Conclusions

Bariatric surgery as delivered in the UK healthcare system is associated with dramatic weight loss, sustained at least 4 y after surgery. This weight loss is accompanied by substantial improvements in pre-existing T2DM and hypertension, as well as a reduced risk of incident T2DM, hypertension, angina, MI, and obstructive sleep apnoea. Widening the availability of bariatric surgery could lead to substantial health benefits for many people who are morbidly obese.     

The Impact of Coronavirus Disease 2019 on Bariatric Surgery: Redefining Psychosocial Care

The global outbreak of the 2019 novel coronavirus disease has had a tremendous psychological impact on individuals around the world. Individuals with obesity are susceptible to distress and psychological sequalae secondary to this pandemic, which can have detrimental effects on obesity management. In particular, individuals undergoing bariatric surgery could experience increased emotional distress, resulting in increased eating psychopathology, mental health exacerbation, and difficulties with self‐management. Addressing these challenges requires novel approaches to redefining psychosocial care before and after bariatric surgery. Emerging evidence suggests that the remote delivery of care using virtual care models, including mobile and online modalities, could extend the reach of psychosocial services to individuals after bariatric surgery and mitigate weight regain or impairment in quality of life. Because of this pandemic, the rapid integration of virtual psychosocial care in bariatric surgery programs to address patients’ needs will create new opportunities for clinical and implementational scientific research.     

Emotional and Affective Temperaments in Smoking Candidates for Bariatric Surgery

Introduction

The prevalence of smoking habits in severe obesity is higher than in the general population. There is some evidence that smokers have different temperaments compared to non-smokers. The aim of this study is to evaluate the associations between smoking status (smokers, ex-smokers and non-smokers) and temperament characteristics in bariatric surgery candidates.

Methods

We analyzed data on temperament of 420 bariatric surgery candidates, as assessed by the AFECTS scale, in an exploratory cross-sectional survey of bariatric surgery candidates who have been grouped into smokers, ex-smokers and non-smokers.

Results

We detected significant statistical differences in temperament related to the smoking status in this population after controlling the current use of psychiatric medication. Smokers had higher anxiety and lower control than non-smokers. Ex-smokers with BMI >50 kg/m² presented higher coping and control characteristics than smokers.

Conclusions

Smoking in bariatric surgery candidates was associated with lower control and higher anxious temperament, when controlled by current use of psychiatric medication. Smokers with BMI >50 kg/m² presented lower coping and control than ex-smokers. Assessment of temperament in bariatric surgery candidates may help in decisions about smoking cessation treatment and prevention of smoking relapse after surgery.     

Bariatric Surgery Patients’ Views of Their Physicians’ Weight‐Related Attitudes and Practices

Objective: A prior study found that nearly 80% of bariatric surgery patients felt that they were treated disrespectfully by members of the medical profession. This study assessed patient‐physician interactions in a group of bariatric surgery patients and in a group of less obese patients who sought weight loss by other means. Research Methods and Procedures: A total of 105 bariatric surgery candidates (mean BMI, 54.8 kg/m²) and 214 applicants to a randomized controlled trial of the effects of behavior modification and sibutramine (mean BMI, 37.8 kg/m²) completed a questionnaire that assessed patient‐physician interactions concerning weight. Results: Only 13% of bariatric surgery patients reported that they were usually or always treated disrespectfully by members of the medical profession, a percentage substantially lower than that found in the previous study. Surprisingly, surgery patients were significantly more satisfied than nonsurgery patients with the care they received for their obesity. Surgery patients also reported significantly more interactions with physicians concerning obesity and weight loss compared with nonsurgery patients. A substantial percentage of both groups, however, reported that their physician did not discuss weight control with them. Discussion: These and other findings suggest that doctor‐patient interactions concerning weight may have improved in the past decade; however, there is still much room for improvement. Increased efforts are needed to help physicians discuss, assess, and potentially treat obesity in primary care practice.     

Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association

ObjectiveHypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients.MethodsThe development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assem bled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incor porated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommen dations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines—2010 update.ResultsTopics addressed include the etiology, epide miology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered.ConclusionsFifty-two evidence-based recommenda tions and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medi cal practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpa tient clinical situations. The standard treatment is replace ment with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.